1 Patient name ______
Psychologist-Patient Service Agreement
Welcome to Dr. Ledley’s practice. This document contains important information about her professional services and business policies. It also contains summary information about the Health Insurance Portability and Accountability Act (HIPAA), a new federal law that provides new privacy protections and new patient rights with regard to the use and disclosure of your Protected Health Information (PHI) used for the purpose of treatment, payment, and health care operations. HIPAA requires that Dr. Ledley provide you with a Notice of Privacy Practices (the Notice) for use and disclosure of PHI for treatment, payment and health care operations. The law requires that Dr. Ledley obtain your signature acknowledging that she has provided you with this information. During your first session, Dr. Ledley will discuss any questions you have about the procedures. Your signatures on this document will represent an agreement with her. You may revoke this Agreement in writing at any time. That revocation will be binding on her unless she has taken action in reliance on it; if there are obligations imposed on her by your health insurer in order to process or substantiate claims made under your policy; or if you have not satisfied any financial obligations you have incurred.
CONSENT TO PSYCHOLOGICAL SERVICES
The first one or two sessions that Dr. Ledley has with patients involves an evaluation of patient needs. Patients will undergo a clinical interview and when appropriate, will be asked to complete self-report questionnaire. The purpose of the evaluation is to establish a diagnosis (if any) and to make treatment recommendations. In some cases, patients will be referred to other professionals following the evaluation. If cognitive-behavioral therapy (CBT) seems appropriate based on the initial evaluation, Dr. Ledley will outline a possible treatment plan. The patient should then decide if he/she would like to work with Dr. Ledley or would like to receive referrals to other treatment providers.
Cognitive behavioral therapy (CBT) is a present-focused, problem-focused, time-limited approach to treating psychological disorders. CBT calls for a very active effort on the patient’s part. In order for the therapy to be most successful, the patient must work on things talked about both during sessions and at home.
As with any treatment, CBT can have both benefits and risks. Since both evaluation and CBT involve discussing unpleasant aspects of life, a patient may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. Often, these unpleasant feelings decrease as therapy progresses. Since the goal of CBT is to teach patients skills that allow them to solve specific problems in their lives, the potential benefit of CBT is an improvement in mood, anxiety, or other problems that the patient faces. There are no guarantees of what any one patient/client will experience during treatment.
I, after reading the above, agree to permit Deborah Roth Ledley, Ph.D. to provide me or my minor child/children with psychological services including evaluations, diagnosis, and/or other aspects of treatment or treatment planning. I agree to participate, to the best of my ability, in my care and treatment. Further, I understand that I have the right to voice any concerns to Dr. Ledley regarding the psychological services that I receive. I understand that I may request a second opinion. I also understand that should I decide to terminate therapy or other psychological services, or change clinicians, I have the right to do so at any time.
I HAVE READ, UNDERSTOOD, AND AGREED TO THE SECTION TITLED CONSENT TO PSYCHOLOGICALSERVICES:
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Signature of Patient (or responsible party if patient is a minor) Date
CONFIDENTIALITY
I understand that the issues discussed during the course of my evaluation or therapy or my minor child/children’s evaluation or therapy are confidential, meaning that information I reveal will not be discussed or shared in any format with others without my knowledge and written consent. My records and the records of my minor child/children will not be discussed or sent to others (excluding insurance companies or managed care companies) without a signed authorization form which meets certain legal requirements imposed by HIPAA. There are several important exceptions to this confidentially. They include:
- Situations of potential harm to myself or others.
- Situations in which my minor child who is being seen by Dr. Ledley may harm himself/herself or others.
- Child abuse, sexual abuse and/or neglect
- Court cases where my records are court ordered
- Insurance companies seeking information about treatment before making payment
- Government agencies requesting information for health oversight activities
- Situations in which Dr. Ledley must defend herself against a complaint or law suit
- Workman’s Compensation Claims
In such cases, Dr. Ledley will discuss the situation with me and share with me any information which is released, whenever possible.
Also, from time to time Dr. Ledley may consult with professional colleagues about my case to get input on how to provide the best care. In these consultations all cautions will be taken to preserve confidentiality. In any situation that may reveal privacy, she will request an explicit release of information from the patient.
I have read, understood and agreed to the section titled Confidentiality:
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Signature of Patient (or responsible party if patient is a minor) Date
POLICIES RELATED TO INSURANCE
Dr. Ledley is not a contracted provider on any insurance panels, thus payment is my responsibility. I recognize that I have the option to submit my claims to insurance for out of network reimbursement, and I agree to pay my fees at the time of services. I understand that if I qualify for a reduced fee based upon financial need, insurance companies may not process my claims.
I have read, understood, and agreed to the section titled Policies Related to Insurance:
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Signature of Patient (or responsible party if patient is a minor) Date
SIGNATURE REQUIRED TO AUTHORIZE RELEASE OF INFORMATION NEEDED TO FILE FOR INSURANCE COVERAGE
I hereby authorize the written and/or telephone release of any and all information including, but not limited to, billing records, diagnostic information, and treatment summaries necessary to process insurance claims. I understand that Dr. Ledley will release only what is necessary to meet insurance requirements. I further understand that when any financial statements, reports or case records are transmitted by electronic mail, or by surface mail to my insurance company or managed care company Dr. Ledley can not make any assurances to me as to who will view these records once they are received.
I have read, understood and agreed to section entitled: Signature Required to Authorize Release of Information needed to File for Insurance Coverage:
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Signature of Patient (or responsible party if patient is a minor) Date
FINANCIAL POLICIES
The fee for Dr. Ledley’s services is $200/hour. The fee per hour is the same for assessment and treatment services. At times, longer treatment sessions might be required (e.g., for a particular exposure, for a home visit, for school observation). These will be billed at $200/hour, including travel time.
A written report of your evaluation is optional and will be billed at $100.
Occasional phone calls might occur over the course of CBT, and when used judiciously, will not be billed. However, any phone calls over 15 minutes in length will be billed for on the quarter hour, at the hourly rate.
Phone calls to members of your treatment team are a normal part of care (e.g., your psychiatrist, guidance counselor, school teacher, etc). However, phone calls over 15 minutes in length that include instruction on the treatment plan will be billed for on the quarter hour, at the hourly rate.
Payment is due at the time services are rendered. Personal checks and cash are accepted in this office. Checks can be written to: Dr. Deborah A. Ledley. A returned check fee will be charged for all checks returned by the bank for non-payment.
Credit card payments are accepted, via Square. A $5 service fee per credit card charge will be levied. Patients can read about the security of the Square system at
Since the practice often has a wait list, it is important that patients attend their scheduled visits. Except in the case of illness or emergency, there will be a charge of one session ($200) for missed appointments which are cancelled with less than 24 hours notice. It is important to note that insurance companies do not provide reimbursement for missed appointments.
If temporary financial problems arise, it is my responsibility to contact Dr. Ledley so that adequate payment plan may be arranged. If it should be necessary to turn my account over for collections, I herein agree to pay all collection-related costs.
I have read, understood, and agreed to the section titled Financial Policies:
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Signature of Patient (or responsible party if patient is a minor) Date
PROFESSIONAL RECORDS
I need to be aware that, pursuant to HIPAA, Dr. Ledley keeps Protected Health Information about her patients in the Designated Medical Record. It includes information about reasons for seeking therapy, a description of the ways in which problems impact life, a diagnosis, the goals set for treatment, progress toward those goals, medical and social history, treatment history, past treatment records that Dr. Ledley has received from other providers, reports of any professional consultations, billing records, and any reports that have been sent to anyone, including reports to an insurance carrier. Except in unusual circumstances that involve danger to self or others or where information has been supplied to Dr. Ledley by others confidentially, a patient may examine and/or receive a copy of the Designated Medical Record, if it is requested in writing. HIPAA provides patients with several new or expanded rights with regard to their Designated Medical Record and disclosures of protected health information. Dr. Ledley is happy to discuss any of these rights with you. Patients under 18 years of age who are not emancipated and their parents should be aware that the law may allow both parents to examine their child’s treatment records. By Pennsylvania law, Psychology Records must be maintained for seven years after the last patient contact (seven years beyond the age of 18 for a minor). After this period, Dr. Ledley may destroy the Designated Record Set and the Psychology Process Notes. Should Dr. Ledley close her practice, her staff will indicate how records can be accessed.
I have read, and understood and agreed to the section titled Professional Records:
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Signature of Patient (or responsible party if patient is a minor) Date
SCHEDULING, BETWEEN SESSION CONTACTS, ON CALL POLICY, VACATION AND EMERGENCY COVERAGE
Dr. Ledley uses Acuity Scheduling (acuityscheduling.com) to allow patients to easily make/change/cancel appointments. Acuity Scheduling is HIPAA compliant ( If you have any concerns about using this site for scheduling, please contact Dr. Ledley. By signing here, you agree to use this site for scheduling needs.
Due to her work schedule, Dr. Ledley is often not able to answer her phone calls immediately. When she is unable to answer, the telephone is answered by her confidential voice mail. Dr. Ledley checks her messages on a regular basis and will return your call as quickly as possible. If you are difficult to reach, please inform Dr. Ledley of some times when you will be available. If you are unable to reach Dr. Ledley and feel that you are facing an emergency, please go to the nearest emergency room or call 911.
Dr. Ledley may also be reached via email at . Email should be primarily used for logistical issues (canceling appointments, asking directions, etc.). You may email Dr. Ledley between sessions if you have questions/concerns about your treatment plan. Dr. Ledley will do her best to email you back as quickly as possible. Email should never be used in the case of an emergency – rather, please go to the nearest emergency room or call 911. Please be mindful that email is not a confidential mode of communication and Dr. Ledley does not use an encrypted email system. By signing here, you have acknowledged that you understand that email is not a confidential mode of communication and you give Dr. Ledley permission to reply to emails that you initiate.
There may be periods of time (e.g. vacations) when Dr. Ledley is either out of town or not available to return telephone calls. In these instances, other qualified professionals will provide coverage for her and will return the call. Should Dr. Ledley become unavailable due to long term illness or death, her colleagues will access your phone number in order to notify you of Dr. Ledley’s unavailability. At your request, these professionals will provide a referral for further care.
By signing below, you give Dr. Ledley permission to reveal your name and phone number and when appropriate, to reveal the reason you are seeing Dr. Ledley for therapy to the professional who will be covering for her while she is away or who will be responding should Dr. Ledley become unavailable due to illness or death.
I have read, understood, and agreed to the section titled Between Session Contact, On Call Policy, Vacation and Emergency Coverage:
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Signature of Patient (or responsible party if patient is a minor) Date
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